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May 2008, Volume 4, Issue 5 - Prevent Pediatric Medication Errors

Dear Colleagues,  

Like the recent Joint Commission Sentinel Event Alert of the same name, Prevent Pediatric Medication Errors is the theme of this month’s Patient Safety Link. A new study acknowledged a greater than 11 percent rate of adverse drug events in pediatric patients, far greater than in previous studies, and further demonstrated that 22 percent of those adverse drug events were preventable, 17.8 percent could have been identified earlier, and 16.8 percent could have been mitigated more effectively. The health care field simply must do a better job caring for its youngest and often most vulnerable patients. We hope you will take the time to read the entire pediatric medication Alerthere. A complete press kit, including the following items, is available here:

    §       Previous Sentinel Event Alerts 
         o        Issue 35 - January 25, 2006: Using medication reconciliation to prevent errors
         o        Issue 23 - September 1, 2001: Medication errors related to potentially dangerous abbreviations
         o        Issue 16 - February 27, 2001: Mix-up leads to a medication error 
    §       National Patient Safety Goals 
    §       Speak UpTM—Help avoid mistakes with your medication 
    §       Facts about The Joint Commission 
    §       A downloadable podcast with Peter Angood, M.D.

We also offer you some additional resources for improving your organization’s performance with pediatric medications. Preventing Pediatric Medication Errors gives practical medication insights, tips, and strategies for leaders and caregivers. In Steps to Preventing Medication Errors in Children, a Joint Commission Resources (JCR) book excerpt from The Nurse’s Role in Medication Safety, a series of simple, practical measures to improve pediatric medication safety for nurses and other frontline caregivers is offered. Medication Errors Involving Pediatric Patientsprovides a summary of pediatric medication errors data submitted to The United States Pharmacopeia’s (USP) MEDMARX® program over a three-year period and includes recommendations for preventing errors in pediatric patients.

Has your organization had success with Preventing Pediatric Medication Errors? Let us know about your success! Send an email by selecting this link:

Peter B. Angood, M.D., FRCS(C), FACS, FCCM
Vice President & Chief Patient Safety Officer, The Joint Commission
Co-Director, Joint Commission International Center for Patient Safety
Laura Botwinick
Vice President, Joint Commission Resources
Co-Director, Joint Commission International Center for Patient Safety
Click here for more information about the Joint Commission International Center for Patient Safety and to read profiles of the directors.

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